Some clinicians request an ethics consult once, but never again. Others never call ethics a single time in their entire careers. Ethicists are left to wonder why.
“We wanted to solicit feedback from our faculty and staff regarding people’s experiences and opinions about the ethics consult services,” says Lynette Cederquist, MD, director of clinical ethics at UC San Diego Health.
Cederquist and colleagues surveyed 150 physicians, 35 advanced practice providers (APPs), and 109 nurses in 2019 on their reasons for never requesting an ethical consult (or, if they had called an ethics consult previously, why they would not do so again).1 Most respondents in each group of providers (85% to 92.1%) stated they had encountered an ethical dilemma. However, only about half asked for an ethics consult. “I was also curious about how nursing and APPs’ responses might vary compared to physicians,” Cederquist says.
The primary reason for not requesting ethics consults did, in fact, differ by provider type. Of 150 physicians surveyed, 41% said it was because they never believed they needed help from ethics. Of 35 APPs surveyed, one-third said it was because they did not know ethics consult service was available. “The biggest surprise was the percentage of long-time faculty and staff who were not even aware we existed. We have had a consult service since the 1980s. I assumed everyone knew we were around,” Cederquist says.
Of 109 nurses surveyed, 30.8% said they did not know how to contact the ethics service. “This surprised me, since we can easily be paged, just like any other consult service,” Cederquist explains.
Just 2.7% of physicians said one reason for not calling ethics was they “did not feel the attending of record would agree,” whereas 16.7% of APPs and 16.9% of nurses said this was the case. “Nursing felt less empowered to impact the course of care of their patients, and had a more frequent sense that ethics consults were not helpful,” Cederquist reports.
Based on this finding, the ethics service conducted additional outreach to nurses by adding weekly ethics rounds on three critical care units. During this time, nursing leaders in the ICU identify a case to discuss. “This has been a great way to let people know who we are and what we do,” Cederquist notes.
Ethicists also encourage nurses to attend annual clinical ethics seminars. Ethicists give an overview of the consult service, and cover care of unrepresented patients, conflicts involving nonbeneficial care, decisional capacity determination, and conflicts between staff. “Don’t assume people know you are around. You may think you are more visible than you actually are,” Cederquist adds.
Cheyn Onarecker, MD, MA, chair of the healthcare ethics council at Trinity International University’s The Center for Bioethics & Human Dignity in Deerfield, IL, says clinicians never request ethics consults for these reasons:
- The clinician did not know an ethics consult was available.
- The clinician had a previous negative experience with the ethics committee.
- The clinician did not think the ethics consult would be helpful.
- The clinician did not recognize the need for a consult.
“The makeup of our hospital medical staff undergoes fairly significant change over a two- or three-year period,” Onarecker notes.
The ethics committee tries to continuously engage with staff to educate members and offer help. “We need to let the staff know that we can do more than just opine on end-of-life decisions,” Onarecker suggests.
Ethics attend medical staff functions and department meetings, send brochures, and place announcements on system screensavers. “We use whatever means are available to remind physicians, nurses, and mid-level providers that we are here to help them care for their patients,” Onarecker says.
The ethics committee is made up of people from diverse backgrounds with expertise in multiple fields. “We are good facilitators when there are conflicts, and we can bear some of the burden of difficult decisions so clinicians don’t feel alone,” Onarecker explains.
Ethicists act quickly on consultation requests and make a point of communicating clearly with everyone involved. “Unnecessary delays and confusing reports lead to physicians being less likely to enlist help from the committee in the future,” Onarecker cautions.
Some clinicians worry calling ethics will result in retaliation or “upsetting the team dynamic,” says Marianne C. Chiafery, DNP, PNP-BC, a nurse practitioner and clinical ethicist at University of Rochester Medical Center. Hospital policy states anyone may make an ethics consult request, and there is to be no retaliation if a person does. Still, clinicians see ethicists and instantly worry, “Does someone see me as unethical?” Some angrily ask why they were not consulted. “We convey that we are not there to judge, but to help,” Chiafery says.
Ethicists meet with new staff during orientation. “We make them aware of the service and ways we can be of help,” Chiafery says.
This does not have to be a formal consult. Ethicists also meet with small groups to work through morally distressing cases, or to debrief after a particularly challenging case. Ethicists do not wait to be called. Once a month, they hold routine meetings on units with a lot of ethically challenging cases, such as the medical ICU or neonatal ICU. “We make connections with persons in palliative care, chaplaincy, and social work,” says Chiafery.
Ethicists treat people who request their help as part of the solution. “This indicates respect and humility, and fosters communication and rapport,” Chiafery says.
In particular, ethicists talk with bedside caregivers to hear their view on the situation. Sometimes, nurses report issues no one else has. Some patients confide, “I don’t want to be put on life support, but my family won’t listen to me.” Surrogates might admit the patient probably would not want aggressive treatment, but the surrogate does not know what to do. “Being part of the conversation and understanding the reasons for decisions empowers nurses. It can mitigate moral distress,” Chiafery says.
Other times, clinicians do not recognize the ethical issue as such. “It’s just a difficult patient or a difficult family. That’s how it gets labeled,” says Zita Lazzarini, JD, MPH, director of the Division of Public Health Law and Bioethics at UConn School of Medicine.
Clinicians fear a formal consult will only complicate matters. “But you don’t need to have a consult come out of every interaction with the ethics committee,” Lazzarini says.
Perhaps after a quick conversation, ethicists realize the person needs to be referred to another department, such as patient relations or risk management. “Sometimes, people just need some support in figuring out the next step going forward,” Lazzarini observes.
In other situations, clinicians simply need to engage in a short conversation about a difficult case. “We don’t always have to get everybody in a room and interrupt people’s schedules. It’s not necessarily going to take up a huge chunk of your time,” Lazzarini says.
REFERENCE
- Cederquist L, LaBuzetta JN, Cachay E, et al. Identifying disincentives to ethics consultation requests among physicians, advance practice providers, and nurses: A quality improvement all staff survey at a tertiary academic medical center. BMC Med Ethics 2021;22:44.
Some clinicians request an ethics consult once, but never again. Others never call ethics a single time in their entire careers. Ethicists are left to wonder why.
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